Senior Sex In A Post-Viagra World

Interest in the sex lives of older people has surged over the past decade. The accelerating trend of population aging around the world, the result of declining birth rates combined with longer life expectancies, has contributed to a growing proportion of the population deemed ‘old.’

These shifts have raised concerns about potential strains on health care resources, and sexuality, through its presumed linkage with ‘healthy’ or ‘successful’ aging, is part of this trend.(1) [Numbered references appear at the end of this article.]

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In place of the old idea of seniors losing interest in sex, a new stereotype — of the ‘sexy senior’, who demonstrates their success in aging by remaining youthfully attractive and sexually active has emerged.

Some of the interest in sexuality in old age has been driven by the development of drugs to treat erectile dysfunction in men, and the subsequent interest of pharmaceutical and other biomedical companies in developing treatments for a range of sexual complaints. There are also generational factors at work: the aging boomer cohort brings a shift in attitudes and expectations towards what late life might look like.(2)

Studies in the US (3), the UK,(4,5) Finland,(6) Sweden,(7) Australia(8) and other countries(9) have repeatedly demonstrated that older adults remain interested in and capable of sexual activity across the life span. Yet tired stereotypes of older people as asexual (or inappropriately sexual) persist.

In addition to, or in place of, the old idea of seniors losing interest in sex, a new stereotype — of the ‘sexy senior’, who demonstrates their success in aging by remaining youthfully attractive and sexually active has emerged. Neither of these contrasting images provides a good basis for promoting sexual health and sexual rights for older people.

Changing Standards of Sexual Health

According to the World Health Organization, sexual health is:

…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.(10)

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Our knowledge of, and willingness to address, issues related to older peoples’ sexuality and sexual health is spotty, but growing. The following should help clarify what the issues are for older people and ease many of their concerns about sex in the golden years.

In the late 19th and early 20th centuries it was widely believed that by age 50 a person should renounce physical love as one’s sexual desires and powers waned. It was considered nature’s plan, for both men and women, that peak sexual desire and power were linked to the reproductive years, and these, once past, signaled a new, sexless phase of life.(11)

Sexuality may change with age, but not necessarily in ways that mean decline, or produce distress.

As new psychological explanations gained traction in the mid-20th century, sexuality was added to gerontology’s ideals of positive aging. Contributions from Kinsey(12,13) and Masters and Johnson,(14,15) among others, stressed that sexual activity could be enjoyed across the full span of life, and that sexuality was a healthy component of successful aging.

Men and women were told they might need to adjust to some physical changes associated with aging. They were urged to learn to continue to enjoy sex as they matured, but to focus more on intimacy and less on performance.

Enter Viagra

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In the 1980s, a different approach emerged as the mechanism of penile erection was found to be a strictly physiological event, separate from any sort of tactile or emotional stimulation, a discovery that paved the way for the development of oral medications to treat erectile dysfunction.

Sexual activity may indeed be linked to healthy and ‘successful’ aging, but there is a risk that the recent celebration of ‘sexy seniors’ may create new pressures for older adults to meet unrealistic standards of sexual function.

When Viagra was introduced to the US market in 1998, both the popular media and the medical establishment hailed it as ‘revolutionary.’ Within months of its approval, millions of prescriptions had been written, a number of mass-market paperbacks hit the stands, stories abounded in the mainstream media, it became the subject of countless comedy monologues and cartoons, and hundreds of internet sites emerged promising discrete online ordering and home delivery. One mass-market paperback crowed, “Now you can have sex when where and how you want, dependably and reliably, even if you’re 100 and your partner’s 102.”(16)

Where's Viagra for Women?

It would be difficult to discuss aging and sexuality without at least acknowledging the impact of the development of sexuo-pharmaceuticals. These have become closely associated with the treatment of age-related sexual dysfunctions. Viagra, of course, became a global blockbuster, new erectile drugs such as Levitra and Cialis have come to market, but the search for an equivalent drug for women has been elusive.

Flibanserin (recently recommended by an FDA panel for approval) has been called “the pink Viagra,” but there is no pharmaceutical equivalent to Viagra for women which addresses the vascular mechanisms of sexual arousal. Flibanserin is a re-tooled antidepressant, which must be taken daily. It has a number of potentially unpleasant or risky side-effects and very limited potential benefits (an increase of about .05 satisfactory sexual encounters per month).(17) There has also been renewed interest in testosterone therapy, but its effectivenss and safety in treating sexual problems in either men or women remain controversial.(18)

Emphasizing Performance and Heterosexual Sex

Like the broader concept of ‘public health,’ sexual health is a social construct whose meaning is derived from particular social, cultural, historical and political contexts.

Sexual health has become increasingly focused on sexual desire and performance where it was once defined as reproductive health and absence of sexually transmitted disease.(19) But when sexual health in relation to aging is so closely associated with particular kinds of sexual capacities, based on youthful, heterosexist standards, there is an implicit message of risk and decline in the absence of intervention.(20-23)

What used to be viewed as a changing sexual capacities associated with ‘normal’ aging are now being viewed sexual dysfunctions that require treatment.

Sexual decline in both men and women was once assumed to be an inevitable consequence of growing older, but now this assumption has been reversed. What used to be viewed as a changing sexual capacities associated with ‘normal’ aging are now being viewed sexual dysfunctions that require treatment. As populations age, the prevalence of sexual dysfunction and the anticipated market for pharmaceutical solutions are predicted to increase dramatically.

So the overriding message has shifted to one of opportunities for rehabilitation to enable performance of penile-vaginal intercourse. Little attention has been paid to prevention of sexually transmitted infections, despite recognition that older adults are now accounting for a growing proportion of new infections.(24)

Almost entirely absent is discussion of non-heterosexual relationships in later life.

Finally, while the new celebration of ‘sexy seniors’ is, in many ways, a development to be applauded, recognizing as it does a capacity for pleasure and intimacy which does not end with the flush of youth, the two extremes — that of an asexual old age and the “sexy oldie” — do not reflect what research suggests about older peoples’ experiences.

What follows is a review some of the key findings of contemporary research on aging and sexuality and a discussion of two key areas where significant gaps in knowledge remain: the sexual health needs of LGBT elders, and STI prevention in older adults.

What Do We Know About Seniors and Sex?

It is only recently that major studies of sexual behavior began to include older respondents. In earlier iterations, both the National Health and Social Life Survey in the US(25) and the British National Survey of Sexual Attitudes and Lifestyles(26) excluded those older than 59! In the past decade, however, several well-publicized studies have investigated the sexual activity of those as old as 94.(3-5,27-30) Key findings from these surveys include the following:

• Interest in sex and frequency of sexual activity does decline with age, most notably after age 75. However, a majority of older adults still see their sexuality as important, and many older people are regularly sexually active even into their eighties and nineties.(3,4,28-30)

• There are significant gender differences, with women as a group reporting lower levels of sexual interest and frequency of sexual activity than men.(27,29)

• Many factors contribute to lower levels of sexual activity as people age, including health problems, age-related changes in sexual function, issues around body image, lack of a partner, and lack of privacy, just to mention a few.(3,27) Biological age alone is not the best predictor of a decrease in sexual interest. More important are overall physical and mental health, attitudes towards sexuality and presence of an intimate partner.(6,31)

• Many older adults report at least one concern about their sexuality, and for some, these concerns cause distress. Frequently reported concerns include erectile difficulties in men, lubrication issues and sexual pain in women, and in both men and women, difficulties reaching orgasm, and lack of sexual desire.(3,5,29) Women as a group reported lower levels of concern and lower levels of dissatisfaction with their sex lives.(5)

While large-scale surveys have been invaluable in putting issues of sexuality and aging on the health promotion agenda, qualitative research has been important in painting a more detailed picture. For example, the decrease in the frequency of sexual activity documented among older people may not be a source of dissatisfaction in relationships,(32,33) nor are changes in sexuality experienced necessarily cause for distress.(34)

Research on Viagra users and their partners, for example, has shown a far from uniformly positive reception.(35-38) While many men can and do use erection drugs, others cannot or do not wish to. Some partners may welcome the prospect of more penetrative sex, others may not. Some complain that there are new pressures to be sexual on demand once the pill has been taken, others (especially older women) regret the renewed emphasis on penetrative sex as the main event.

Given that almost half of prescriptions for erection-enhancing medications are not renewed, it’s clear that they are ‘magic bullets’ for all men.(39) A number of studies have demonstrated that penetrative sex may not dominate the repertoire of older individuals, who can be both inventive and playful in their intimate encounters.(40-42)

Issues Facing LGBT Seniors

As noted above, one of the shortcomings of biomedically-driven models of sexuality has been its focus on penile-vaginal intercourse in the monogamous, heterosexual couple as the normative form of sexual expression. This not only limits our understanding of sexual practices among those who identify as heterosexual, it fails to even put non-heterosexuals on the map. So, even less is known about sexuality and aging in lesbian, gay, bisexual and transgendered (LGBT) individuals than in those who identify as heterosexual.

Anywhere from 20-30% of LGBT older adults do not disclose their sexual or gender identity to their physician.

While it is difficult to know precisely the proportion of older adults who identify as LGBT, estimates suggest that this is between 3% and 8% of the US population.(43,44) An increase in the aging population, coupled with increasing LGBT social and legal acceptance, will likely mean that LGBT elders will become more numerous and more visible.

The invisibility of LGBT elders is certainly related to the historical de-sexualization of the seniors more generally, but just recognizing the sexuality of older adults is not sufficient to encompass their concerns.(45) Many in this population matured sexually in an era when same-sex relationships were not only stigmatized but criminalized, making invisibility a key survival strategy.

An Uneasy History

Someone turning 65 in 2015 was born in 1950, which means that when they came of age, homosexuality was still included in the DSM as a psychiatric disorder, and medical interventions may have included aversion therapy and electroshock treatments aimed at ‘curing’ them.(45) It is not surprising, then, that many remained closeted.

These LGBT seniors are not confident in relying on health care systems that have historically discriminated against them, and many are not willing to disclose their sexual identity to their health care providers.(45) Some LGBT elders who have been living openly, “now find themselves returning to the closet to avoid anti-LGBT bias on the part of service providers”(45). Studies suggest that anywhere from 20-30% of LGBT older adults do not disclose their sexual or gender identity to their physician.(46,47,48,49,50)

Transgender Seniors

Once among the most invisible of older adults, the special challenges that may face transgendered persons in later life have recently been highlighted by the very public transition of Caitlin Jenner, at 65, as well as similar fictional portrayals in the critically-acclaimed television series Transparent.

Transgender elders may have special health care needs related to both physical and social aspects of aging. Some transgendered individuals may identify as heterosexual; others may identify as lesbian, gay or bisexual, suggesting that these needs may overlap with those larger groups. However, they also face some issues specific to gender transition.
Little is known about the long-term effects of life-long hormone treatments or other medical interventions related to physical transition. Transgender individuals also vary in the extent of surgical reassignment they have undergone. There is no doubt that the sex-segregated nature of most long-term care facilities may make the prospect of residential care especially difficult for transgendered elders to contemplate navigating.(51)

It is important to keep in mind that, like their heterosexual counterparts, LGBT elders are not a homogenous group, but are shaped by gender, race, geographical location, socioeconomic status and age, among other factors. In general, a perspective on sexual health that embraces sexual diversity suggests that whatever their sexual or gender identity, older adults are entitled to express their sexuality and to have access to information and services which will enable them to do so in a personally fulfilling and safe manner.

One aspect of aging and sexuality, which has received insufficient attention, is prevention of sexually transmitted infections. Older adults are, on the whole, less aware of the risk factors for HIV than younger people, and more likely to engage in risky sexual behaviors, including unprotected intercourse.(52,53) Older heterosexuals, for example, who enter into new relationships after finding themselves single in later life may not see the need for condom use when pregnancy is no longer a concern.

However, research shows that rates of sexually transmitted infections, including syphilis, chlamydia, gonorrhea and HIV/AIDS have rapidly increased among older people in recent years.(54,55) STIs are also likely to be diagnosed at later stages in older people — perhaps because they perceive themselves as being at low risk and/or because of embarrassment in requesting testing. Practitioners, because they may not perceive older patients as at risk for STIs, may also ignore symptoms or delay diagnoses.(56,57)

Rates of sexually transmitted infections, including syphilis, chlamydia, gonorrhea and HIV/AIDS have rapidly increased among older people in recent years.

As with other age groups, risk behaviors vary by gender and sexual identity, with men who have sex with men remaining the largest at-risk group.(58) However, HIV rates among heterosexual women over the age of 55 have been rapidly increasing.(55)

A number of studies have suggested that older women in particular do not see themselves at risk for HIV,(3,59,60) yet women may be at particular risk for infection, partly due to physiological changes associated with menopause, such as thinning and drying of vaginal tissues that make them more susceptible.(56,57) One study found that only 2% of older women were aware that they had a greater risk of contracting HIV than a younger woman in any given episode of sexual intercourse.(61) Very few of the women in this study (3%) had received any HIV-prevention education from their physicians.

The Sexual Health Needs and Sexual Rights of Older People

One of the biggest obstacles to sexual health among older people is their reluctance to raise their sexual concerns with health care providers, who themselves may also be unwilling (or unprepared) to initiate discussions about sexuality.(62-64)

Sexuality may change with age, but not necessarily in ways that mean decline, or produce distress.

Additionally, even though many medications older people may be taking have potential sexual side effects, doctors frequently do not mention these, perhaps out of their own discomfort or because they did not feel they would be of concern to older patients.(65) “If doctors leave it to older adults to ask about their sexual concerns, and older adults leave it to their doctors to raise the issue, then a clear unmet need exists,”(66) researcher Sharron Hinchliff notes.

Finally, while it is important to recognize that sexual activity may indeed be linked to healthy and ‘successful’ aging, there is a risk that the recent celebration of ‘sexy seniors’ may create new pressures for older adults to meet unrealistic standards of sexual function. Sexuality may change with age, but not necessarily in ways that mean decline, or produce distress.

References

1. Lindau ST, Gavrilova N. Sex, health and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of aging. British Medical Journal 2010;340:810.

3. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A National Study of Sexuality and Health among Older Adults in the United States. New England Journal of Medicine 2007;357:762-74.

4. Mercer CH, Tanton C, Prah P, et al. Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). Lancet 2013;382:1781-94.

60. Henderson SJ, Bernstein LB, George DM, Doyle JP, Paranjape AS, Corbie-Smith G. Older women and HIV: how much do they know and where are they getting their information? J Am Geriatr Soc 2004;52:1549-53.

66. Hinchliff S. When it comes to older people and sex, doctors put their heads in the sand. The Conversation. June 19, 2015. http://theconversation.com/when-it-comes-to-older-people-and-sex-doctors-put-their-heads-in-the-sand-43556